Collateral Damage

Rounding Up the Usual Suspects: Grand Finale

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Spring training seems like it is right around the corner, although from where I’m writing from, winter still hasn’t arrived (we’ve only had about three inches of snow in Boston this season). One of the great things about spring training is that you never have to worry about snow. On the other hand, injuries will happen regardless of the weather outside.

Over the last few months we have talked about the ”usual suspects,” that is, the kind of injuries we see over and over. How common are they? To answer that question (and hopefully not bore everyone to death), I brought a bunch of graphs. There are also doughnuts for everyone at the back of the room. In the first graph, we have the breakdown of usual suspects disabled list injuries, with the data collected for the years 2002-2011. There is some overlap between a few of the categories, (most notably with fractures). It probably won’t surprise you that pitchers make up a large part of the shoulder and elbow injury categories (such as rotator cuff, labrum, or Tommy John surgeries). Abdominal strains are more spread out; understandable when you consider that the number of swings a hitter takes during the season is often more than the number of pitches a pitcher throws throughout the year. Other injuries, however, are less discerning in their targets: Knee injuries, hip injuries, and fractures are all equal opportunity disablers, with only the DH managing to miss out on the party.

Another way to look at it is to see how the different types of injuries make up the whole of all baseball injuries. Out of these usual suspects, almost one-third concern the shoulder while another 24 percent involve the abdomen or the elbow.

To give you an idea of the discrepancy between injury rates for pitchers and position players, take a look at the graph below. Over half of all the DL stints are for pitchers (when I wrote this, an Eddie Murphy Raw quote came to mind: “Half. I’ll take half his…”). A key point to consider is how relief pitchers have gotten hurt at a greater rate than starters, dampening the theory that pitching injuries are solely related to high pitch counts. Outfielders rank third, but this is misleading since there are three of them on the field. When we take all of that into account, every other non-pitcher on the field stands roughly the same chance of ending up on the disabled list.

It would be nice if all of the days missed due to injury averaged evenly, but this is only wishful thinking. The discrepancy actually worsens here, to the point that 60 percent of all disabled list days are missed by pitchers. All other positions average around five percent.

So, we have the basics, but that’s not all the information we need. Preventability is what separates players who last in the majors and the ones who don’t. Knowing how to prevent injuries is how team medical staffs can make the biggest impact on the field, and consequently on the bottom line. There will always be inherent risk for some injuries, like fractures, concussions, and dislocations, but you might be surprised to see how poorly some positions do.

Injuries like sprains, fractures, dislocations, concussions, ACL tears, meniscus injuries, and contusions are, for the most part, not preventable. One can argue that the chance of any injury can be lessened through improved balance training or reaction time, but with these particular problems the best we can do is moderate the degree of injury, not avoid it altogether. On the other hand, we have shoulder inflammation, rotator cuff tears, labrum tears, Tommy John surgery, elbow inflammation, disc problems, and many types of strains that are more preventable. Clean-out surgeries were included in this section because of the pathomechanics associated with these conditions, while sports hernias are also included because of their chronicity.

As the graph below shows, preventable injuries are much more common than non-preventable ones. All position players, except for DH, have non-preventable rates of at least 40 percent. On the other hand, pitchers come in rock bottom, around 12 to 13 percent each. This means that over 85 percent of all pitching injuries have a large component of preventability, a staggering number... but not as staggering as what is coming next.

Here’s what will blow you away: 10 percent or less of all days lost due to pitching injuries were due to injuries that were unpreventable. In this ten-year period, over 100,000 days lost to injury for pitchers had some level of preventability. That’s over 273 calendar years. Shoulder inflammation, abdominal strains, and Tommy John surgery are all taking their toll, but to some degree these were avoidable injuries.

We will never be able to avoid all injuries, but think about what could happen if we were able to cut that number in half. Your favorite players would stay on the field longer, and general managers would not have to waste money on injured players. The quality of play would improve, leading to more parity across the league. This has been possible for some time; teams just need to invest as much in their medical staffs as they do in filling out their roster

This strikes me as argument by assertion. You assert that a variety of maladies have a large component of preventability, but it certainly appears that most organizations are trying to prevent them, and pitchers still get hurt.

I think the reason more pitchers get hurt is that throwing the ball that much or that frequently with that velocity is bad for you. I disbelieve that the majority of the pitching injuries are preventable. Well, I suppose almost all of them are preventable - Adam Wainwright wouldn't have hurt his arm if he were selling insurance rather than pitching.

If these were preventable, I'd like to see a chart of actual pitchers and what could have been done to prevent these injuries. Without that, your argument is raw assertion. Sure, Mark Prior and Kerry Wood had preventable injuries. But tons of guys break when they are being handled quite carefully.

Just because teams try to prevent them doesn't mean that they are necessarily good at it.

I don't have a chart as to each pitcher and what could have been done but with the injuries themselves certain things could have been changed.

Fatigue of the flexor mass at the elbow means more force will be put on the UCL of Tommy John fame during the late cocking and early acceleration phase. The pitcher can improve the muscular endurance or strength to decrease force placed on the UCL.

Oblique strains are a result of strength imbalances along with fatigue as are most shoulder strains.

Shoulder and elbow inflammation results from microscopic damage when a little too much force is placed upon the muscles because of improper mechanics, fatigue, or weakness.

All of those things can be addressed although some of it is present by the time the team gets the player, especially at the MLB level with free agency.

But improved strength and conditioning, more time off between appearances, better recognition or admittance of fatigue, and learning how to pitch effectively at a decreased velocity instead of blowing the ball by people can all help to solve these preventable injuries.

History is not a repeatable experiment, so I understand there are limits to the methodology. Still, to take one aspect of this, are we asking all pitchers to slow down their delivery? Hey, Justin Verlander, you're throwing too hard? What evidence is there that guys who throw 98 get hurt more than guys who throw 92? If not everyone, how do we decide which guys to slow down? And slowing down pitches impacts performance negatively.

The Rangers seek very hard throwers and run them hard. Are they wrong to do so?

How much more time between appearances do we need? Isn't it an easy post hoc explanation to say "strength and conditioning" when someone gets hurt?

Can't you have shoulder or elbow inflammation without improper mechanics, or diagnosable fatigue or weakness? I'm no athlete, but I hurt my shoulder doing approximately nothing. An explanation which explains everything explains nothing; we can ascribe all of these injuries to something after they happen.

If you can predict future injuries with good accuracy, then I withdraw all of this and I am duly impressed. But if you're saying that all these pitcher injuries are preventable if only the teams weren't so dumb, I remain skeptical.

It seems to me that the argument Corey presents is that a type of injury which comes from repetition as opposed to trauma is inherently more preventable, something that I think can be agreed upon, if not the degree of likelihood to which it can be prevented.
You comment also reminded me - Corey/Rebecca - is there a plan to do a pre-season team-by-team injury-risk assessment series?
This series, while sometimes going over my head, was very informative.

In terms of maximum velocity, here's one entitled "Association of Maximum Pitch Velocity and Elbow Injury in Professional
Baseball Pitchers found here: http://ajs.sagepub.com/content/38/4/728.short

and this one entitled "Correlation of Torque and Elbow Injury in Professional Baseball Pitchers" found here:
http://ajs.sagepub.com/content/38/7/1368.short

Maximum velocity is associated with elbow injury but I would be more concerned about max effort guys.

Not every injury in the "preventable" group can be 100% fully prevented because every risk factor is still being researched. Sure you can have inflammation sometimes without one of those things above. People sleep wrong, people have old acute injuries that cause chips, etc. That's why I said it would nice to cut the above number in half, not 100%.

I'm certainly not saying that I can predict future injuries with excellent accuracy yet or else I would be a very very rich man. I'm not even saying that it is the team's fault so to speak, although it may have come across that way. The player and the team need to work together but it is more on the player than anything else with the player movement across teams we see today.

I would agree with the author that injury prevention is a huge inefficiency in MLB. It probably offers more potential in cost savings and competitive advantage than any other aspect of the game. Smart teams are investing in this, and serious fans want to know more about it. Great stuff Corey! Keep it coming!

A few more final thoughts. Several years back I remember Will Carroll mentioning that the technology that would allow each organization to do it's own bio-mechanical analysis on every pitcher in their system was in the cost range of $50K, and incredibly at that time no team had invested in it. This would seem to be a no-brainer to help pinpoint the risks in a pitcher's delivery to help coaches change any mechanical flaws early on, thereby preventing blowouts down the road. It would seem that this analysis could also be applied to a hitters's swing to prevent (or at lest diagnose earlier)oblique, hip, and knee injuries. Of course nothing can eliminate injuries completely, but I would have to believe that this type of thinking is the present for some & future for all injury risk management at the professional level. Lots of room for improvement here.

I don't think you're wrong, but I also think that the athletes who are nimble enough to remain at the up-the-middle positions tend to be younger, and the younger tend stay healthy (except for Chase Utley).